As NPs push for expanded practice rights, physicians push back

Posted March 19, 2010, 12:02 p.m.

(Page 2 of 4)

Squaring off

“The title doctor is not owned by physicians,” says Ellen Beth Daroszewski, PhD, the director of the DNP program at Western University of Health Sciences (WesternU) in Pomona, Calif., the parent institution of the College of Osteopathic Medicine of the Pacific. “I am a doctor because I have a PhD.” She contends that physicians’ desire to reserve doctor for themselves is “ego-driven.”

Dr. Daroszewski, a nurse practitioner whose doctorate is in nursing, refers to herself as doctor in both academic and clinical settings. “Patients usually call me Dr. Ellen or Dr. D,” she says.

Editor’s note

The DO and other AOA publications use the title Dr. for all individuals with a doctoral degree in an established field.

Dr. Daroszewski notes that she always introduces herself as an NP and corrects anyone she hears referring to her as a physician, even though California is one of 33 states in which nurse practitioners with doctorates are not legally obligated to clarify that they are NPs when patients address them as “Dr.” While she believes that most patients at the NP-managed clinic she established in San Bernardino, Calif., know that she is a nurse practitioner with a doctorate, it wouldn’t surprise her if some patients assume she is a physician.

“Patients tend to call everyone in a clinical setting ‘Dr. So-and-so,’ whether addressing a male RN, a physician assistant or even a lab technician,” Dr. Daroszewski points out, noting that most clinicians will correct the patients. She says there is no evidence that such initial confusion on the part of patients causes harm as long as patients are receiving high-quality care.

If patients mistakenly believe that they are already being treated by fully trained and licensed physicians, they may fail to seek appropriate medical care when they become seriously ill, counters Dr. Kase.

Published by the American Journal for Nurse Practitioners (AJNP) in February 2009, the latest version of “The Pearson Report” contains passages and statistics that seem to validate physicians’ misgivings about NPs’ intentions. “NPs must continue to strive to remove statutory restrictions that prohibit NPs with earned doctorates from being addressed as ‘doctor,’ ” writes Linda J. Pearson, MSN, the report’s author and a consultant to the AJNP.

“The Pearson Report” gives each state and the District of Columbia a grade from A to F, with A signifying the most autonomy for NPs, based on whether NPs with doctorates can be addressed as “Dr.,” require physician involvement in any aspect of practice, have the authority to prescribe controlled substances, have hospital privileges, and satisfy more than a dozen additional criteria.

“To call oneself a doctor is a far cry from being a physician,” contends Dr. Goldberg, the dean of the Touro College of Osteopathic Medicine in New York City, as well as a former president of the Medical Society of the State of New York. “The health hazards posed to patients are great when people seek medical care from limited-practice individuals in the belief that such individuals are physicians.”

To thwart such arguments, “The Pearson Report” purports to demonstrate that NPs have much better patient-safety records than do DOs and MDs. The report draws on data from the National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank, which compile the number of accumulated malpractice judgments and adverse actions, licensure actions, civil judgments and criminal convictions levied against NPs, DOs and MDs. Pearson computed the ratio of the number of accumulated reported occurrences against NPs, DOs and MDs during the previous 18 years to the number of NPs, DOs and MDs who were in practice. When she applied this formula to malpractice judgments and adverse actions, the “overall national occurrence ratios” were 1 in 173 for NPs, 1 in 4 for DOs and 1 in 4 for MDs. Applying the same formula to adverse action reports, civil judgments and criminal convictions yielded the ratios of 1 in 226 for NPs, 1 in 13 for DOs and 1 in 23 for MDs.

“NPs must use these malpractice and malfeasance ratios and figures to show legislators that the rationale for physician supervision over NPs in unfounded,” Pearson emphasizes in her report.

But physicians shoulder more responsibility than NPs, perform riskier procedures, treat more seriously ill patients, and correct the errors of NPs under their supervision, Dr. Yasso argues. In addition, trial lawyers prefer to target physicians with malpractice lawsuits because they have more substantial professional liability insurance coverage than NPs typically have.

Dr. Daroszewski insists that nurse practitioners are forced to defend themselves against repeated attacks from physician organizations on NPs’ training, ability and patient-safety records. She also points out that dentists, podiatrists, clinical psychologists and other doctoral-level clinicians have long used Dr. titles in their practices without triggering the physician outcry that “doctor nurses” have.

Rising momentum

Coinciding with the establishment of Medicare and Medicaid, the first nurse practitioners were trained in 1965 to help relieve shortages of primary care physicians, particularly pediatricians.

To become NPs in the early years of the profession, registered nurses completed additional schooling that ranged from an intense four-month continuing education program at a university to a two-year nursing school master’s degree program. By 1986, NPs needed at least a master’s degree in nursing.

A key factor in nurse practitioners’ growing momentum, the Balanced Budget Act of 1996 gave NPs the authority to bill Medicare for their services anywhere in the country and in any practice setting allowed by state laws. Their numbers surging from approximately 250 NPs in 1970 to almost 90,000 in 2000 to more than 139,000 today, nurse practitioners have promoted themselves as both serving the underserved and providing lower-cost yet high-quality and safe health care.

While some nurse practitioners today do practice in physician shortage areas, the overall geographic dispersion of NPs resembles that of physicians, according to research by the American Medical Association.

Let’s be honest. This is an argument about market share by the some physicians and not about patient care. I applaud the physicians who are willing to work collaboratively and see the larger picture and don’t simply jump on the bandwagon of their political lobbying organizations (AMA and AOA). The argument about who is a “doctor” is ridiculous. It is an academic title and physicians are not entitled to make the rules and decide that PhD’s, DC’s, DNP’s, DDS/DMD’s, DVM’s, DPT’s, OTD’s, OD’s, PsyD’s, AuD’s, PharmD’s, ND’s, DPAS’s. DMin.’s, DBA’s, and any other doctorally prepared individuals can not call themselves by their earned professional title.

NP’s, CRNA’s and CNM’s are competent healthcare providers and there are hundreds of studies to validate that fact. Look at the evidence. It is even published in JAMA on more than one occasion for those of you who don’t want to look at non-physician journals. The inflammatory, slanderous, unfounded antidotal statements are unprofessional, unnecessary and possibly a point for legal intervention. It is simply the tactic of fear mongering and is harmful to all involved. The reality is that the healthcare system is in dire need of reform and a combination of care by providers is essential.

Let’s stop wasting everyone’s time, resources, and energy arguing about this frivolous issue and focus on how we collaboratively provide patients with the healthcare they need.

I am interested in a career in health care because I care about patient’s well being. This article/website really turns me off to becoming a DO. I thought DO’s were supposed to care about the whole person and provide a different approach to healing. Instead, comments made by DOs are outright arrogant, leading me to believe the “fear” discussed in the article is more about prestige than patients. There is more focus on creating a divide between health care practitioners than encouraging an open discussion for improving care and team work.

Just want to make clear to Kristin what the NP movement is
really all about- a power and money grab, as well as the
theft of an honorary title by the mechanism of degree
inflation. The evidence that NPs want a lot more than
just to serve patients and increase access to primary care
is present in two distinct places:

1). In Iowa, the NPs are trying to establish the right to
supervise RADIOLOGY procedures.

Yet, nursing schools and the DNP do not even require one
year of college physics. So, NPs demand this “right” and do
not even understand basic electromagnetic radiation concepts!

Evidence at AMA website under advocacy and scope of practice-
the AMA has had to SUE Iowa Board of Nursing to prevent the
utterly absurd from coming about.

2). AT the University of South Florida the NPs are trying to
establish a “residency” in DERMATOLOGY-far less rigorous and
time-consuming than REAL residencies in Dermatology.

Two EXCELLENT examples that put the LIE to the claims of the
NP movement with its “DNP” degree- that is to” increase access” to
care.

General Statement: For ALL the licensed physicians in the United States,
their medical license was earned with blood, sweat,
and tears. Even the D.O. schools have been very
selective in recent years with MCAT and GPA
requirements at many now equal to several state
MD schools- and acceptance rates among thousands
of applicants of 5-10% at many D.O. schools.

Following the intense hurdle to GET IN medical school,
it takes enormous effort to graduate and get a good
Residency- and pass USMLE/COMLEX- ALL THREE FULL
STEPS- 5 1/2 days of testing in aggregate-and perhaps
a thousand questions. { at the last book of STEP 2, I actually
started to see the last 2 pages oscillate out of the plane-an
illusion of mental fatigue}.

Then: RESIDENCY with thousands of hours of work and call
for 3 years minimum followed by: Another Exam.

Now, most docs see their title as “teacher” BUT also as a
respected honorific for all that work, debt and sacrifice.
And so it has been for decades.

Now, enter the NPs- what are their demands? What are their
qualifications? With FAR LESS education and training they
arrogantly demand equal status and full practice independence.
They even invent a new “DNP” degree, just so they can be called
“doctor.”

As any economist will tell you, INFLATION cheapens the currency and
amounts to THEFT by other means. The NPs seek to STEAL
(by theft) the very honorific used in clinical settings that define
who doctors are and what they had to accomplish to become
doctors. IN THE CLINICAL(NOT ACADEMIC) SETTING.

And this is theft-by-inflation from those that actually earned the
title.

It is very much analogous to wearing military honors on your
person never actually earned in Combat or in Service to your
country- a thing which REAL soldiers and veterans despise and
loath with good reason.

So go right ahead-call yourself doctor so-and-so. Inflate the title.
I will happily remind everyone who the REAL doctors are- and what
they had to sacrifice to become so. WHY? BECAUSE I WILL NOT
ALLOW YOU TO STEAL FROM ME WITH ALL YOUR POLITICAL
RHETORIC.

At the end of his life in Athens, Socrates was attended by
his followers and friends in an Athenian jail. Legend has
it that as Socrates made his goodbyes, he had one request
of his fellow Athenians:

Socrates bade that his friends should severely CHASTISE his
sons if ever they pretended to be MORE than they really were.

For Socrates knew that the first step to wisdom was
self-knowledge and intellectual honesty-even in
the days of Socrates there were politicians and academicians
who pretended to know and to be more than they really were.

The NP movement vividly demonstrates that even today,
in Century 21 America, the same phenomenon thrives.

Consider, for example the NP argument that they provide care
equal to the MDs- as proven in their “studies”.

A little reflection demonstrates they have proved nothing of the
kind. What they have shown AT MOST is only that NPs, when
acting under supervision or in collaboration or with the
ability to refer to physicians can THEN provide comparable care.
That is, their care is equivalent ONLY when they are HOOKED INTO
the medical care system-by one way or another. If they had NO
physicians to consult or refer to- and no hospital to take care of
patients-they could not possibly provide equivalent care.

The D.O.s, on the other hand, BUILT their own hospitals and specialists-
and over DECADES of hard work, GRADUALLY achieved equivalency with
MDs. Now, of course, the D.O. system is very intertwined in the regular
medical practice- in all fields-even neurosurgery and cardiac transplant, etc.

A very far cry from the NPs.

Kristin’s sharp post perhaps reflects the sting of the truth that
Socrates pointed out- and that remains as true today as it was
in the time of ancient Athens.

I read your article with much enthusiasm and in my humble opinion as a Board Certified Family Psychiatric Nurse Practitioner practicing independently, although this is a wonderful example of marketing, in all likelihood this was designed to garner emotional responses and facilliate feedback for discussion.

Suggesting as this article consistently documents you opinions versus evidenced-based practice material, consideration be given to referencing contrary or supportive journal literature or articles.

The medical profession has been far too
soft and politically correct in dealing with the NP movement.

“Board-Certified ” family psych nurses!

Going to take a short, watered-down version of the
(easiest) step 3 of the Boards of NBME,
OMIT the science-based tough parts, and then
start calling themselves “doctors” based on
the “DNP” degree in statistics and nursing theory.

And there you have it- a nice brand new “board-certified”
“family pysch” “doctor”- WHO IS REALLY A NURSE.

This kind of blatant, in-your-face theft from the medical profession
is allowed only because we are far too soft, will not take the tough
decisions to fight this kind of arrogance.

NP=POLITICAL CORRECTNESS GONE WILD.

Who is Mudinger to tell all of us what qualifications are needed
to practice primary care medicine?

Is medicine really going to allow Mudinger to lead a revolution that
forces all the docs to specialize just because she invents inflated degrees
and phony titles and says that she and her gang can do the same job
for less investment and training?

If we strategize with the physician assistants and associates and
work out, with the state legislatures,
methods of allowing them to
run their own (satellite) primary care offices with the docs in contact
by tele-medicine/phone on a rotating basis, we CAN put these
NPs OUT OF BUSINESS. One good general Internist can partner with
4 or 5 physician associate practices and QUINTUPLE the patients and
geographic areas served- WITH MD/DO referral and subspecialty care
available very quickly.

WE NEED TO AGGRESSIVELY PARTNER WITH PAs. EVERY MEDICAL
SCHOOL SHOULD HAVE A PA PROGRAM to ACCOMPANY IT.

WE NEED TO AGGRESSIVELY PUT NPs OUT OF BUSINESS,
OR ELSE WE WILL END UP GIVING UP ALL PRIMARY CARE TO NPs-
the nation is so strapped for money and resources that politicians
will eagerly buy into the baloney put out there by the NP
profession BECAUSE IT WILL BE POLITICALLY EXPEDIENT FOR
THEM TO DO SO- all under the guise of politically correct
sounding PROPAGANDA.

The recent stats out of the USMLE show that, for the 2008
part 3 exam, BOTH the MD and DO passing rates were 95%

NINETY-FIVE PERCENT.

Also the USMLE step 1 (basic sciences) passing rates were on the order of
96% and 81% for MD and DO respectively.

Kudos to the Osteopathic medical schools for producing
physician graduates who, overall, are essentially the same as the
regular LCME US MD graduates. Even the basic science difference is
now quite small, so that the vast majority [>4/5] of D.O. physicians
have the same academic training and accomplishments as their MD
counterparts.

And the NPs? With the nice new “DNP” degree??

Only 50% [FIFTY PERCENT} managed to pass the SHORTER,
EASIER (different passing standards) version of the
NBME step 3 using the “old, retired” question bank.

More than anything else, this points out the VAST DIFFERENCE
between fully-educated physicians and the NPs.

And then, the docs have to take the ABIM certifying exam which
makes the USMLE look like a high school exam.

This data can easily be used to demonstrate that giving the NPs
independent practice rights amounts to nothing other than creating
a distinctly second class of “junior doctors” without the full training
and qualifications of real physicians. This data should be presented right to
the legislatures each and every time the Nurse lobby keeps pushing
for independent practice.

Why are there no mentions of PharmD or chiropractors, etc, who should not use the title doctor? Why is it just nurses who can not use the title doctor? Could it be that decades of talking down and looking down at nurses prevents them from looking at us as being highly educated. We do not want to replace physicians in any way, we are just another health care provider trying to care for patients. Advanced practice nurses know there roles and what there competencies are. Having a DNP does not increase pay or reimbursement rates in any way. I find physicians try and say that patient safety is their main concern when they discuss political issues, but that is just because it wouldn’t sound as effective to say ,”but that might make my salary or client base go down.” or ,”I am just jealous that someone I view as inferior and not under my direct control wants to provide some of the services I provide.”

Just view the post earlier about pairing PA and medical schools together; not for patient safety but just to maintain control.

Anyone with a doctoral degree has the right to use the title when introducing themselves. Although I do agree they would have to be very careful not to represent themselves as physicians. It might be confusing for a little bit, as it is with many changes. The public will get used to the idea of other advanced care providers that aren’t physicians. A nurse practitioner, anesthetist, or midwife who introduces themselves with the title doctor should follow up immdediately with their role. “I am Dr. SoAndSo and i am a nurse practioner.” If physicians don’t like this than they should introduce themselves the same way and state they are a physician.

No one has the right to deny someone else a title they have earned, as long as that person is not trying to pass themself off as a physician.

Finally, I would like to point out that I know of no DNP or DNP candidate that ever applied to medical school. I am tired of hearing that nurses who want a doctoral degree just want to be a doctor and couldn’t get into medical school. I am proud of being a nurse and never wanted to be a doctor, I am a CRNA.
I have alot of respect for most physicians, but there lifestyle and schedules are aweful. I would never choose that for myself. That is just my opinion. I know my practice boundaries and can respect that they have a broader education than I do. Their broader education doesn’t make them any better at delivering anesthesia than me. Does spending extra time learning a little about pscychiatry, obstetrics, dermataology, etc. mean you can understand anesthesia better? I think not. I manage anesthetics, not diagnose and treat schizophrenia (or any other disease for that matter). It is enough to know how those drugs and disease states effect the anesthetic, I don’t have to be able to manage therapy for them.

Excepting federal service, chiropractors and PharmDs do not work in the same clinics and hospital setting the that the physicians do. There is no chance of confusion. They have very well-defined roles and, in my experience, they do them very well.

The NP profession is an entirely different matter.

The nurse practitioners are constantly lobbying the state legislatures for ever larger scope expansion, year after year, every year without fail. Those nurses are not genuinely attempting to add something new or better to medical practice except ONLY cheaper labor costs. Therefore, they make no effort to build science departments or medical schools to advance the practice of medicine itself.

What a stark contrast to osteopathic medicine, which laboriously built its scientific base and its medical schools and hospitals to try to actually add a another dimension to standard medical practice. After most of a CENTURY of such improvements, ONLY THEN were they accepted into MD training programs and residencies. Thus, with no doubt in my mind, the “osteopaths” laboriously and MERITORIOUSLY EARNED the right to become PHYSICIANS. Today, for the most part, they are accepted by regular physicians as colleagues and partners.

NOW come the nurses-first with NP “masters” programs and now the DNP (which has only a few clinical science components, no basic science, and far, far less hours and work than just bare medical school graduation).

And what, in all honesty, are the objectives of this NP profession?

I claim the objective is entirely to replace all primary care physicians with the cheaper alternative- the DNP-easy to grow them, easy to seed them, and now the cheap aspect can be a huge selling point to insurance companies and government. And that is the reason for endlessly pushing for independent practice.

Worse- I feel certain that the NPs are fundamentally intellectually dishonest-

How? In that they have attempted in many places to move health care practices that have always been labeled “medicine” by the several states TO the Nursing Board and then get those same practices RELABELED nursing.

Mudinger herself makes the argument that primary care physicians are over- trained for what they practice- WHO IS SHE TO BE THE JUDGE OF THAT??

The DNP is absolutely a cheap knock-off for a medical diploma, under the guise of greater access to medical care. With its far inferior academic standards, it is an absolute insult to the REAL doctors who had to sweat to get into and through medical school and residency to be called “doctor” when caring for sick human beings.

In contrast, the DNP can even be earned on-line in some cases. If that is not a phony diploma-mill degree, I surely do not know what would so qualify.

So NO, it is NOT about “control”-its all about honesty and recognition of one’s genuine limitations. And PLEASE do NOT expect me to ever believe that with a “doctorate” in “nursing practice” AND with a state license that is in REALITY a full, unrestricted license to practice medicine ( the DNP ulterior objective), that somehow the DNP will remember her actual knowledge base and when to seek help in diagnosis and treatment. They will certainly diminish the truth in practice and tell the world( as many already do) that “I am just like a doctor, except for the pay.”

If the DNPs are allowed to achieve their ultimate objective, I cannot see how patients with unusual medical conditions masquerading as regular conditions (eg: Churg-Strauss prodrome appearing as simple allergic rhinitis), can possibly be safe in the hands of such “doctors.”

The solution for medicine is to aggressively partner with PAs to meet the nations needs, NOT to aid and abet this DNP take-over- primary care agenda.

I would even say that the PAs are better trained with more scientific knowledge of medicine than the NPs.

One final point: that the DNPs are really stealing from the medical profession rather than adding something new or unique, can be seen NOT just in their new DNP degree (so they can get the title)- but even in calling their small post-graduate training programs “residencies”.

So, whether we are willing to say so or not, the medical profession knows exactly what these nurses are pulling here- and the nurses should be ashamed of this behavior (DNP “dermatologists”) at USF.

But what bothers me the most is that medicine is not standing up for itself with anything like the vigor and commitment it SHOULD stand up with to expose and abolish this kind of fakery. In part, this is because medicine seems to be engaged in countless battles with government and insurance companies and it has truly become a profession under constant siege.

“Doctor” is Latin for “teacher,” coming from the word root of “docere,” which means “to teach.” It signifies a person of great learning; this person is recognized as having received a diploma of the highest degree in areas such as divinity, law, literature, medicine, nursing, etc. The doctorate originated in medieval Europe and was originally used by the Catholic Church to indicate persons authorized to teach the Bible. However, the University of Paris was granted permission in 1213 to expand this academic education to a universal license to teach, as in philosophy. One of the greatest early religious philosophers to come out of the University of Paris’ doctoral education system was Abelard. To restrict this word to only mean a medical doctor hijacks the original definition and hinders full understanding of a doctorate education and the various professionals who achieve this highest level of learning, such as DNPs. Rather than reacting in fear and anger, can we not collaborately educate the lay public and other professions in the use of this word? (Please note I am a DNP student and NOT a NP).

No one is “restricting” the title of teacher [“doctor” ] to medical doctors.

You bring a false charge.

No one suggests that Ph.D.s in physics not be called “doctor” in
schools-or, even better, professor.

Neither the M.D., the D.O, (and certainly not the DNP) is
considered the “highest” academic degree by Universities in the U.S.
The Universities consider the highest degree to be the Ph.D.- a research degree.

The argument here refers to use of the title “doctor” in CLINICAL settings, in
seeing patients-where the term has long been reserved by tradition in the
United States (and, for non-surgeon physicians in Europe) for physicians only.

The demand by DNPs to be called “doctor” in the United States in CLINICAL
settings therefore is tantamount to its logical equivalent- to be considered
and recognized as a physician by patients, physicians, insurance HMOs,
government and so forth. {Although disclaimers are issued concerning the
true goal of the DNP movement, once it gets established, I believe those
disclaimers will be conveniently ignored).

Thus, your history lesson is quite irrelevant. Your appeal to emotionalism
as rationalization for attempting to steal what others actually earned
is in reality a great discredit to the DNP concept. My earlier post about the
wisdom of Socrates applies- he strongly desired at the end of his life that,
should his sons attempt to falsely represent themselves as (having accomplished)
more than they really have, they should be severely rebuked by the ancient
Athenians.

NPs with only masters’ degrees are even now often mistaken for fully trained
physicians in clinical settings.

There is no doubt in my mind at all that the rush to quick and cheap DNP degrees
is a political movement with a nakedly political agenda-to displace primary
care physicians- the real docs that actually went to med school-and replace them
with “DNPs”. Mudinger’s own propaganda makes this apparent.

You must ask yourself if your “DNP” program really meets the standards of
intellectual integrity-as opposed to political posturing and propaganda
in disguise.

Although you may be willing to fool the public ( which is really tragic), you may
well find that you cannot honestly fool yourself.

You labor under a further misconception:

The great Universities here and abroad firmly believe that no individual
truly becomes a master of his/her discipline until they make a unique,
substantial and worthy contribution to that discipline that is UNIQUELY
THEIR OWN. Then, and only then, is the Ph.D. degree conferred.

That process of unique and original contribution is what scholars and
academicians consider to be “the highest level of learning.” It CANNOT be
achieved by course work, or by passing ANY examination, including the
USMLE, the ABIM, or even the rather silly “cheap and short” version of the
Step III exam that the Nurse lobby recently conned the NBME into producing
(where the NBME’s motive was profit, and who cares about the rest of the medical
profession).

Medical degrees are considered to be “first professional” degrees.

It is apparent that you believe that your DNP- degree -to -come will
represent the “highest level of learning”.

That is not even true for genuine medical degrees, in the manner that the
great Universities define it. [One cannot get any degree from Yale without an
original thesis, so great is their commitment to this ideal-I have an M.P.H. from
Yale, besides a medical degree].

So, with all your history lessons, learn also the truth-what the “highest level”
of learning REALLY is considered to be-you will find it rather unrelated to
the issues of professional practice, despite the propaganda put out by the
Nursing lobby and agenda.

Skeptical internist….I do believe you have what we call “short-man’s syndrome”…. You’re DO/MD degree obviously defines WHO you are and not WHAT you are. The idea that I chose to further my education in nursing, does not give you or anyone else the right to down play my credentials. I make certain my patients know I am a NURSE, you do not need to fear!!! With the reputation “DOCTORS,” oops, I meant “REAL DOCTORS” have today in the healthcare industry, puh-LEASE call me a NURSE! :)

I applaud your obvious skepticism of this attempted takeover of the Primary care marketplace. Its clear that this degree only seeks to serve the egos and pocketbooks of NPs, as well as the pocketbooks of the educational institutions conferring degrees, because we know: The more units you take, the better the universty does.

Its unfortunate because this degree does little to advance the practice of medicine or to improve the quality of care provided to patients. You cant tell me that the NPs with Masters degrees will provide inferior care than that of a DNP, at least you cant make that argument based on the posted DNP cirriculums.

While I am also skeptical of the production of this clinical Doctorate, I do believe that there is a real need for Physician Extender programs to have more Doctoral trained professors. In my opinion, this would improve the educational experience that PA/NP programs would get, especially from a research standpoint. Academically, a doctoral program is a good idea.

Another area where I disagree with you is that NPs are clinically inferior to PAs. It is clear that PA education is superior, both with clinical rotation time and the academics mimicking that of the Physician medical model. However, NPs overcome this early obstacle in their career based upon real- life RN experience. We as providers have all known RNs that have taught us something or saved our behinds in some way…these are the nurses who go on to become NPs. After 3-5 years, PAs and NPs function at the same level, being excellent adjuncts to physicians who both provide quality and cost-effective care.

The separation of PAs and NPs is simple, its a desire to expand and have independence in their practice rights. PAs want to be adjuncts to physicians. PAs responsibly fill the physician void and do not seek independence. If you want independence go to Medical school, get in substantial debt, and take on more malpractice risk. Deal with it, we have less training, thats ok, we can still provide a valuable service to our patients without a status title. MIDLEVELS-DONT LET YOUR EGO GET IN THE WAY OF WHAT YOU HAVE CHOSEN TO DO FOR YOUR PATIENTS.

Unfortunately, In our competition based society, I believe PA education will follow the entry-level Doctoral path that PT/OT/DNP, etc has already taken. The argument will be, I am more highly trained and educated because I have a Doctorate. For many, this will be an effective argument. This has already sparked fierce debate among the PA community. Just look at the blogs! PA programs will compete for business by having a “higher status” than other programs, and so on and so on…Also the chance to increase the number of units taken will eventually prompt this change in degree conferred.

So the title of doctor will become a mute point. The issue is how it is used in a clinical setting where patients can get confused.

Seeking for further independent practice rights does not improve the quality of healthcare it only improves the billing rights of NPs, so this is a separate issue than degree title.

I am a firm believer that PAs/NPs are imperative to the healthcare fields survival. As long as midlevels dont get overly-ambitious in their quest for a larger piece of the pie.

Trying to get a derm residency started?? That USF program has been available since 2007. In addition, other residencies are available. Funny how MDs now own the term “residency”.
If we are so substandard, why do patients come to us for care and why are we such a threat? Trying to deceive the public? Every patient calls me “doctor” and every one of them knows EXACTLY who I am. All patients get a bio telling them what my educaton/training consists of and many comment on how impressed they are that nurses can have this advanced training. Very sad all this bad behavior from people who perceive themselves as superior to us. What does Socrates say about that?

According to “DNP”, the people who do NOT agree with her/his position all exhibit “bad behavior.”

The skeptical DNP believes I have “short-man” syndrome, because I do not drink the cool-aid the Nurse lobby is pushing on this nation.

All of these are forms of “argument ad hominem”- the logical fallacy of attacking the man who makes the argument, rather than the argument itself.

Most forms of appeal to today’s “politically correct” “standards” are in fact a kind of ad hominem argumentation for not meeting the social standard of political correctness.

The current generation of Nurse leadership fairly swims within vast pools of politically correct thought and virulently anti-physician propaganda.

For many, many decades, the term “residency” in the clinical training of physicians was exclusively used, in the healthcare settings (hospitals) to refer to physicians undertaking required post-graduate training.

Now, attempting to push political correctness to its logical extremes, “DNP” suggests that, in fact, physicians have never owned the term, and that DNPs now have the express right to use that term also.

The bigger and more outrageous the lie, the greater the likelihood the public will believe it, as Nazi propagandists always understood.

But “residency” is a term we use in our professional practice.

No doubt the DNPs will start creating “fellowships” and “DNP fellows”.

Also, the fact that “people come to us for care” demonstrates nothing- people once went to snake-oil salesmen for care also. People come for care because they are sick and in need of help.

The chicanery and fraudulent behavior thus demonstrated will continue, unless and until state or federal statutes can be enacted to stop it.

On another note, here is yet again further evidence of the debasing of medical practice in the United States- the frightful lowering of standards that the Nurse lobby is virulently and, in my opinion fraudulently, pushing on the public:

1). Attorney John H. Fisher reports on Client “Z”, a 48 year old male with fever of unknown origin seen on several occasions by a nurse practitioner at his primary care physicians’ office, but never by the primary care physician.

After three months of the same symptoms, Client “Z” succumbed to a massive stroke secondary to bacterial endocarditis.

The nurse practitioner prescribed Motrin for his pain symptoms, apparently not recognizing subtle life threatening signs.

Could a doctor have missed this also? Of course.

But now the point: Was an internist AS LIKELY to have also missed it?

Absolutely not. Internists are so used to life-threatening conditions from thousands of hours in hospital RESIDENCIES (the real ones), so that the odds are far less likely for an Internist to miss this.

The same is true for the family physician, and for the same reasons.

Mr. Fisher’ conclusion: ” This case illustrates the risks of expanding the role of nurse practitioners. Simply put, a nurse practitioner does not have the medical education, training or experience to handle complicated cases that should be handled by a physician. Unfortunately, many nurse practitioners believe that they are just as qualified as physicians and they see no reason to limit their patient care to uncomplicated or routine cases.”

Practically a “doctorate” of political correctness, whose students one suspects are anticipating equivalence with real doctors (physicians) in willful, gleeful ignorance. Without all that tough organic chemistry, biochemistry, gross human anatomy, those nasty USMLE steps one and two and three, and then that painful residency and board certification exam.

Yes indeed! Equal pay for the “same work.”

I re-iterate: the best solution for the medical profession is aggressive promotion of physician assistant and associate programs- with their scientifically based approach, as well as stressing the need to support primary care residency for family medicine physicians.

Emphasis placed on physician associate programs will increase the science-based practice of medicine as well as increasing the pool of people who, IF THEY SO CHOOSE, would also make excellent primary care physicians if they then, later on, went to medical school themselves.

Aggressively partnering with physician associates will also allow primary care physicians to maximally extend SCIENCE-based medical practice to the largest percentage possible of the population.

This knot comes untied when we look at it the other way. Do you see anyone suggesting that physicians LOWER their training standards because the NP standard is sufficient for patient care? Of course not. People do not seek the doctor who is just good enough. People also regularly sue for malpractice. I suggest that NP’s get equivalent training for equivalent privileges. THAT is what is in the patient’s best interest!

I do not think the present standards for patient care is adequate for patient care. NP’s have 1 year of clinical rotations that may not require much reading. This places them near a third year medical student. I recently hired a NP. Although she is already an asset to my practice,and continues to improve clinically, she still requires a great deal of supervision.

If nurse’s are pretending to be doctors I invite them to go to medical school and play the part to par. The sad reality for many medical graduates who will not match through ERAS or the scramble after wasting their youth in medical school and accumulating a heap of debt as a possible and very existing solution to this alleged doctor’s shortage in accommodation of inadequate care is given by folks who want to play doctor. Not every case that comes to the the GP is a URI and I hazard ask if the folks pushing for such a change would themselves like diagnosis and management by a nurse?

PA’s prescribe, NP’s prescribe, and now psychologists prescribe in New Mexico and Louisiana. Perhaps we should allow 3rd year medical students the “right” to prescribe. They have more education and training in medicine than any of the above. I have observed PA’s “practicing medicine” in a critical care setting and have been horrified. I have worked with a few sharp NP’s but mostly average to below average NP’s with very limited knowledge regarding medicine, caring for very ill patients. All of these disciplines cite malpractice claims as their measure for proving they practice safely. What they fail to tell you is, that when working collaboratively with a mid-level practitioner, the collaborator is responsible for the malpractice. Attorneys do not go after the NP, PA or “medical psychologist.” They sue the doctor in collaboration.

This long-winded discussion is goofy! Look at yourselves arguing and presenting self-validated logic! Angry, frustrated, upset,worried,invalidated, paranoid? Stop this ridiculous discussion & go back to taking care of patients as you originally intended! If you are good at taking care of patients, they will know it, everyone else will know it, and most importantly YOU will know it! You will be secure in what you do! There are plenty of patients for all of us..we will all be fine. The saddest person in this string of commentators is “Skeptical Internist”. He or she is off base about a lot of his arguments, statistics, spends too much time trying to validate him or herself, especially in still holding onto the old “DOs are almost as good as MDs paradigm”. I work with numerous NPs & PAs and feel no threat. I know what I do and I know what they do, providing high quality care is the final product! If “Skeptical Internist” was as good a physician, and secure in his role as a physician as he should be, he wouldn’t have the time to write to this website as much as he has! He would be too busy taking care of patients! Obviously he has lots of free time, I suppose the practice ain’t doing too well? Time to get a life my friend!

As a first step towards gaining parity – NPs and DNPs can demonstrate their sincerity, by insisting they be accountable to the same oversight board to which PAs and physicians are accountable. In my state, NP/DNPs are accountable to a different board than PA/physician (i.e.Office of Professional Misconduct.) Every physician and physician organizations must contact their representative and demand this requirement. Sadly and for obvious reasons, nursing organizations are against this.

As a second step NP/DNP training must change – After obtaining their undergraduate degree, working a few years as a nurse then completing only 36 hours of course work (WHICH CAN BE DONE ONLINE) and 850 hrs of clinicals, NP’s have the legal right to prescribe potent analgesics, psychotropics, antiarrhythmics, etc with minimal oversight. Strange that I had to complete thousands of hours of course work, clinical training and pass 3 comprehensive boards before I gained that legal right and before I felt competent enough to assume that right. So now the NP applies to the DNP program at Columbia University which indicates 40 credits are needed to completed its program (number of clinical hours is not disclosed on Columbia’s web site) and subsequently feels they should be allowed to practice INDEPENDENTLY. Any NP or DNP who feels they should be entitled to those rights does not understand the practice of medicine and presents as a danger to society.

After working in an office for a short period of time with a Nurse practitioner and a Nurse Practitioner student, I quickly learned that much of what I have read in the previous paragraphs is true. Nurse practioners do see themselves as the future of Health Care. And what a sad and scary thought that is. I was quick to see that my approach to patients was very different to that of the NP. I am there to help patients become informed about their illness and hopefully see to it that they take care of themselves to either manage or eliminate the disease process. The NP I worked with seemed to care more about being liked by the patients and wouldn’t do anything to make a patient unhappy. I try to practice build and want a patient to come back, but I am not trying to run for office. I hope demonstrating my knowledge and approachability would speak for it self, I don’t worry about a popularity contest, but seem to do just fine anyway. The NP’s definetly cringe and become angry when they are categorized and Physician extenders. But the reality becomes apparant when they can not sign off on orders from Home Health Companies and other Durable Med benefits as a PA or NP. They also earn less than a Physician as they should. What angers me the most is the way they can be autonomous in their license to practice but the malpractice companies still seem to classify them as an Physician extender. For that reason their yearly malpractice premium is a mere fraction of what I pay. They have not been named in enough cases where they are held responsible since since traditionally they work under a doctor and the captain of the ship kicks in having the Physician liable in the end. As these clinics in grocery stores and the like hire NP’s to practice with out Physicians they will learn that they are responsible in the end for a patients well being and will go after them when they make a mistake. But until that happens they stand to make a fortune since they can practice medicine without paying high malpractice premiums and as they become licensed as a DNP they may even start earning a similar salary as a Physician which is a slap in the face to all of us who have incredible debt that follows us from all the education and certification fees we have had to pay and be responsible for. This article and the comments above made me smile, since I thought they were getting away with something and am so happy the DO’s are looking into this.

I agree with SFII. The NP’s with whom I have worked don’t know their limits. They don’t acknowledge what they are incapable of managing. Often, I see them them actually calling other hospitals to inquire the “next step” because they’re embarrassed to actually be supervised by a physician who is way younger than them, but who outnumbers them in hours and rigor of training. Some NP’s will now dig their claws into these statements and say I’m probably not a good physician and that’s why they don’t come to me before calling for help..Um. Right. They avoid asking ANY of the physicians in the clinic, because they don’t want to consider themselves inadequate in any way. Just had an example recently involving a man having an MI in our clinic. A physician should have been notified in the facility first…before any calls were even made to an accepting a physician at another hospital.
I recently even had an argument with one who refused to do a pelvic on a patient, arguing that the left lower quadrant pain in an otherwise healthy menstruating woman in her early 30’s did not require any type of pelvic exam, because her symptoms of diarrhea, nausea, and fever clearly were of GI origin on no basis. The pain was in the suprapubic and left lower abdomen. Right. That clearly means GI because it could not possibly be of pelvic origin and cause diarrhea….and that was their reasoning. Plus, we wouldn’t want to offend the patient and do a physical exam on them that seems to intrusive, right? They do come do a clinic and do want to be diagnosed, but let’s just skip exams that may make a patient uncomfortable or, for that matter, a provider uncomfortable.
Should we really let them screw up patients first and then retract the priveleges we let them gain? A foreign doctor who has practiced 20 years can’t even practice under supervision temporarily to be eligible for a US license…they have to redo an entire residency just to practice in the US. Why in the world are we not limiting the autonomy of nurse practitioners before it is too late?

Wow! I am flabbergasted! I am on graduate school and visited this site for a holistic health course. My primary provider is a homeopath. I can’t believe the immaturity if physicians/interns on this page.

Thank you secure physician. You are poised and confident, I would choose you as a provider 20 times before seeing a DO so ignorant and arrogant as skeptical internist and some others. Skeptical internist is pompous! He/she will not display their name. Why don’t you let everyone on this site know who you are. SKEPTICAL INTERNIST IS A COWARD! I wonder what his/her upbringing was like, I fear for his/her patients. I (as do many others) disrespect physicians that are more interested in making a name for themselves. Jesus was known for his works and dealings. How will others remember you? A well-educated MD, pompous, high strung, miserable, and more concerned about who is called doctor than providing high quality care. I am so sorry that maybe how some of you will be remembered. You will be humbled in due time. Pride before fall haughtiness before crash. P.S. Many nurses hold Ph.D’s look at the DNP curriculum. A nurse has no problem saying they are a nurse. Respect others and they will respect you. Don’t feel so threatened.

We can all take note of the use of the
descriptive pejoratives “pompous”:, “ignorant”
“arrogant” and “coward” in Shirley Robert’s posting.
Not to mention the religious reference, because
certainly, God must be on Shirley’s side.

As most of the posters here are aware, these are all
trivially the “argument ad hominem” , abusive variant,
well known to any college graduate who has intensively
studied logic and philosophy. This “argument” is
depressingly common in political discourse.

To attack the man, not the arguments made by the man.

For Shirley’s sake, I point out that, even when Adolf Hitler
correctly argues the proof of the Pythagorean Theorem, we
are all constrained to admit that Hitler (or Jesus) or whoever
is correct, if the ARGUMENT made is correct.

“skeptical internist” is used in open acknowledgment of the
seminal work of a key physicist/chemist that was instrumental
in turning Alchemy into the modern science of Chemistry:

“The Sceptical Chymist or chymico-physical doubts and
paradoxes, touching the spagyrist’s principles, commonly called
hypostatical, as they are wont to be Propos’d and Defended by
the Generality of ALCHYMISTS.”

by the Honorable Robert Boyle, published in London and usually called
the Skeptical Chemist, for short. In 1661.

Now my argument is simple: To wit, that the Nurse Profession,
with all of the trappings of political correctness, has introduced the
“DNP” degree as a “practice doctorate”, specifically with the implied
intention to replace/supplant family practice physicians with a cheaper
and, according to them, more patient-friendly alternative.
They introduce many studies to “demonstrate” the accuracy of their claims
for equivalence, but a careful review of them demonstrates such claims are
based only on the most commonly diagnosed and easily treated conditions
prevalent in the general population.(diabetes,hypertension,asthma)

Thus, in a very real manner, the Nursing profession is attempting to mislead
and deceive the public by their actions.

For the DNP to claim real equality with physicians, and so qualify for unsupervised
medical licenses, they must prove equal knowledge of medical science and of
clinical medicine.

Here are two pieces of evidence that demonstrate that NPs/DNPs do NOT have anywhere
near the medical science knowledge that physicians virtually universally have:

1). DNP performance on USMLE part 3-the simpler, shorter and “dumbed down”
version of the exam has a pass rate (set by NURSES themselves) that is only
1/2 the rate at which real physicians pass this easiest of licensing exams. Even
DNP cherry-picking and cherry-grading their exams demonstrates precisely the
OPPOSITE of what they claim.

Of course, DNPs will not even attempt STEP I in all its glory- they know they have
not REALLY gone to medical school, don’t they.

2). See the recent IOWA court decision preventing NPs from arrogantly presuming
the qualifications to supervise fluoroscopy and other radiologic procedures
in that state- the attachments appended by the Judge in the Court speak
enormous volumes about the arrogance and political ambition of the nurses-
and, as we all know, nursing programs require NO University Physics-let alone
the study of ODEs or PDEs of Maxwell’s field equations that are really needed
to understand radiation and its effects on matter. Of course, the nurses will
tell you that none of that matters. Thank god for the Judge in Iowa who saw
right through the baloney and prevented injury to Iowa patients and citizens.

In the Iowa District for Polk County, Consolidated Case # CV8252.

Finally- a review of the DNP degree curriculum demonstrates a “doctorate”
in social and political correctness attempting to pass itself off as a scientific
“practice” degree.

Any legitimacy accorded the DNP represents a lowering of standards and will
result in making medicine LESS scientific, not more so.

We cannot convince the DNPs and NPs of the clear chicanery of their position
in this discussion- theirs’ is a POLITICAL movement, not a search for truth.

What we can do is to aggressively develop PA programs, which are actually
based on medical SCIENCE, not Healthcare Political Correctness.

I propose that the best way to maintain high standards of practice and sound,
rigorous scientific training is to aggressively partner with PAs to give the best
medical care possible to the greatest fraction of the US population that
we can.

I came to this website as I am a nurse practitioner and a psychologist. It is unfortunate that anyone would have to argue all of this, but suddenly I have nurses at work arguing that I should not be addressed as doctor.

I make it crystal clear that I am a nurse practitioner for a number of reasons. In medicine we look at treating diseases, in nursing we treat how the patient responds to the treatment. I am proud to say I am well-rounded and versed in both, and a psychologist to boot. The argument over training is interesting as I work in addictions, which few Doctors are interested or trained in. I have worked in this field for 23 years and it is unlikely any schooling could have provided this expertise. I am constantly in training as theories, medicines etc evolve.

So my complaint is this: I don’t believe for a second any nurse pracfitioner doesn’t introduce themselves as Dr. B, a nurse practitioner, because that is our selling point. We are the top of our profession and should be proud to be so. Yes, we practice medicine and yes we do so with an approach that differs from medical doctors, our training as nurses is rigorous and believe me does count toward patient care. While everyone was getting a Bachelors in some undergraduate specialty, we were fully studying patient care. With a two year associate degree, we spend another two (year round) years only to get a second associates degree, then two more years for a Baccalaureate. Then three more for a Master’s in Nursing and three more to become an NP. These all include clinical rotations. None of which are political.

So, as we find out more about the human body It becomes clear we need this holistic approach. I did not do a rotation in surgery as a medical practitioner and this would not likely benefit my practice, but should you have an issue with addiction I suspect I deserve to be called my academically earned title of doctor.

But here I am, still paying for my PhD student loan and actually having nurses argue over this point.

NP PhD,
Many of the NPs in my area are awarded their NP after only 4 yrs of UNDERGRADUATE training (college) then 30 credits obtained ONLINE and 850 hrs of clinical experience. This training does not come close to the breath or depth that a physician is required to obtain. Yet, with this paucity of training NPs are able to prescribe potent drugs and treat complicated diseases. Any NP who feels they can practice medicine with these credentials is a danger to their patients. And finally, just as I have no right to represent as a academician to students at a college or university (since I am a clinician), you have no right to represent yourself as physician which is the implication when you address yourself as doctor in a clinical environment.

This is where I am confused with all of this. I have never said I am a physician, as I am not. I am ,however, a psychologist. I make it very clear I am a nurse practitioner and in the field I work we call psychologists “Dr.”. So i am gathering I do not acknowledge my PhD or that I am a psychologist because I am a nurse practitioner. This makes no sense. You are taking a leap saying “implication”. I think the only implication may be from those feeling threatened.

There is no implication when we address ourselves as nurse practitioners. You see, if we say just nurse, then patients expect nursing. We practice medicine. According to studies, we do it well. And the reality is this is evidenced-based.

Unless someone is out there calling themselves doctor who hasn’t earned the academic title, I don’t see this as a logical argument. I suspect the issue is that patient’s don’t understand that nps practice medicine and it has to be explained, hence the confusion.

So when you speak at a college you clear it up with students that although you are a physician you are not a teacher, despite the latin “doctor” implication?

Truly a remarkable posting. As I read it, I cannot help
but observe some glaring contradictions, while simultaneously you
make statements that are honest in the sense of revealing what the NP
movement is really all about.

The honesty is refreshing.

You must be aware, are you not, that all of the NP propaganda is that
NPs practice “advanced practice NURSING” and NOT medicine. After all,
where is your “Nursing Model” as opposed to the “Medical Model”?

Yet you openly and honestly admit that you practice medicine.

However, you are completely comfortable with the fact that you are NOT
SOLELY regulated by your State Board of Medicine (I presume) and therefore,
I assume you are comfortable with not being held to the same standards
required to practice medicine that the physicians are held to.

In short, if you practice MEDICINE, especially independently, you should
be regulated by the State Board of Medicine (exclusively). The SAME standards
should apply for the SAME privileges. ( How simple is that?)

You also state that you are well-rounded and well versed in BOTH
the professions of Medicine and Nursing. This claim is at least theoretically
possible for any individual, but the problem is not one of isolated
individuals or cases. The objective data from the USMLE is that 50% of new
DNP grads fail the easier and shorter version of Step III, the longer and harder
version of which all new physician grads pass (while INTERNS) at a 95% plus
rate.

The conclusion cannot be escaped: even DNP nurses lack the basic
knowledge of physicians before they even do their Residency. And Step 3
is entirely CLINICAL.

Would you care for a crack at Step I (Medical Science)? To be graded
just as the physicians are graded, mind you. No special easier, shorter exam
with NURSES setting the Pass/Fail standard instead of Doctors.

How about a nice round of a two-day special called the
Internal Medicine In-Training Exam?

Sure, you are “well-versed” in Medicine.

It is just that Physicians are a heck of a lot better versed in Medicine, and
that is what it means to be held to a higher standard- a standard that begins
in University and is maintained throughout medical school and residency.

As far as Psychology goes- I have actually worked with my wife, a
Psychiatrist, at a State rehab facility, and, if NPs know very little medical
science, Psychology knows none. They incorrectly concluded, for
example, that a patient with advanced hepatitis C and liver cirrhosis
had an improvement in his mental functioning due to “talk” therapy.
In fact, he improved on lactulose, which improved his hepatic encephalopathy
leading to clearer mentation. Likewise, they do not recognize the mental and
neurological impairments of advanced vitamin B-12 deficiency.

Again, the “studies” cited (Mudinger et al and the like) invariably
study only the most common acute and chronic illness invariably seen in
adult medicine ( asthma, hypertension, diabetes). Essentially, NPs claim
equivalence broadly based on management of a relatively small number of
common diseases. Obviously, this does not mean that YOU as an individual
do not have broader experience. But because NP programs and standards are
so widely variable, one must examine the average status of NP training and
standards. When this is done, the purported equality is readily seen to be
political propaganda.

But here is the REAL “kicker” in your posting:

>” I work in addictions, which few Doctors are interested or trained in”<

While this statement may be true, it ALSO reveals that you RECOGNIZE that
you really are NOT a "Doctor" in the Clinical sense that the term has been used
in for many, many decades in the Western world, despite the rest of your
arguments. Of course, a Ph.D. is a "Doctor" in the academic sense.

This tells me clearly that, whether you admit it or not, you recognize a great deal
of truth in what the physicians have been saying all along. Obviously, not
openly admitting this is the preferred course of action when attempting to
obtain prescribing psychologist rights and independent NP rights by
POLITICAL means-intensively lobbying State legislatures.

I hope this clears up confusion. I also hope that the "nurses at work"
understand my points as well.

One further point: None of the above denigrates the wonderful contributions
Nurses and Nursing makes to patient care, or the contributions Psychologists
make to the care and improvement of personality disorders and other
psychological disturbances in people.

Unfortunately for Medicine and for Nursing, the NP movement has rolled out
its DNP degree and wants NP "residencies" etc. This clearly qualifies as
trying to be doctors, despite their propaganda to the contrary. Their actions
speak far more loudly than their words- so loudly do their actions speak,
that the NP verbiage and propaganda cannot be heard over the volume of
their actions.

I find it hard not to be defensive when the profession of medicine is politically being challenged…there is a true threat out there. However, let me say that as a former Hospital Corpsman, LPN, and RN I’ve had my share of “arragant doctors” to deal with, but they were few and far between and don’t count. The ones that do count are the hundreds of doctors (both MD and DO) that I have worked with over a 27 year period of time who I never felt inferior to, or degraded or demeaned while working with them. I respected them and were inspirred by them. I was a very good RN; I felt and knew I was making a valuable contribution and I knew I was an intelligent human being.
Then, I decided to become a physician, and was willing to do anything I needed to do to make that happen. I wanted to continue developing mentally, emotionally and spiritually. I wanted the autonomy, the control, the mentally and emotionally challenging work, and the monetary compensation for the knowledge and skills I earned. And, I wanted the full responsibility and full accountabilitiy that goes along with it all, and the commitment to life long continuing education. Having a doctorate degree and being called “doctor” doesn’t make me a better person, but it does make me a different person, with a different set of societal responsibilities and accountability. And having been a nurse previously, I know the whole “battle of the sexes” that went on back then, and evidently still today.
It’s going on in the medical profession as well, and in every other profession out there. It is the hugh spiritual challenge we all get to work on, no matter what profession we are in, or walk of life. The issue of practice rights and who gets to be called what will continue to be played out in the courts because I understand people will be people, and always want more and feel justified in pursing more. My prayer is that a Higher Intelligence gets the final say in the matter, and a Higher Justice will prevail. Meanwhile, I continue to create the life I love, and send love and light to everyone who’s intention is to relieve the suffering of others.

So when greeting your patients how do you introduce yourself? Do you say “I’m Dr Smith, nurse practitioner”, or “I’m nurse practitioner Dr Smith,” or “I’m Dr Smith, NP” or any number of other very confusing combinations. I am board certified in addiction medicine and medical director at 2 clinics, so I am acutely aware that many patients in the addiction treatment environment probably assume you are a physician if the designation doctor has ever been associated with your name by you or your staff (this is undeniably true if you also write for meds.) In all likelihood, this association has occurred since your staff probably books you with the following dialogue “Mr Jones we gave you an appointment with Dr Smith at 10am.” Even the way you refer to the people you treat can lead them to the wrong conclusion, since those in the medical field use the reference ‘patients’ whereas non medical (MSW, PhD, etc) use the reference ‘clients’. It would be interesting to know how you refer to them – as patients or as clients.

In my opinion, unless you and your staff plainly and consistently convey to your clients in no uncertain terms, that you are not a physician, but a nurse with some specialized training, who holds a doctor of philosophy in psychology, you and your staff are by omission, misleading your clients. I doubt this can be accomplished in a plain and consistent manner. So that there is no misunderstanding let me state emphatically I am not attempting to minimize your PhD training which I understand is considerable but I respectfully suggest that in that clinical environment you refer to yourself as therapist Smith, PhD which is your proper designation and not Doctor Smith so as not to mislead your patients.

Incidentally, I have never, nor do I intend to, teach at any university or college because I understand my limitations in that I have not been trained as a teacher but rather a clinician. Neither do I consider, or pass myself off, as a researcher since I also lack that training. You, on the other hand, may very well have that teacher/researcher training and thus would have every right to feel indignant if I breached your academic domain leaving that impression by omission .

NP PhD wrote 4/2/11 –

” This is where I am confused with all of this. I have never said I am a physician, as I am not. I am ,however, a psychologist. I make it very clear I am a nurse practitioner and in the field I work we call psychologists “Dr.”. So i am gathering I do not acknowledge my PhD or that I am a psychologist because I am a nurse practitioner. This makes no sense. You are taking a leap saying “implication”. I think the only implication may be from those feeling threatened. There is no implication when we address ourselves as nurse practitioners. You see, if we say just nurse, then patients expect nursing. We practice medicine. According to studies, we do it well. And the reality is this is evidenced-based. Unless someone is out there calling themselves doctor who hasn’t earned the academic title, I don’t see this as a logical argument. I suspect the issue is that patient’s don’t understand that nps practice medicine and it has to be explained, hence the confusion. So when you speak at a college you clear it up with students that although you are a physician you are not a teacher, despite the latin “doctor” implication”

Dear Skeptic
If NPs are skeptical physician extenders; are skeptical physicians NP extensions? Might we surmise then that a skeptical physician is akin to a snap-on-tool? Make no bones about it, my diagnosis is ubiquitus statusitsmyturficus related to anal retentive tendancies, paternalistic pathology, with excessive valsalva manouvering as evidenced by mechanistic dystonia and rabid verbosity. In the olden days a DRA and some paraldehyde might have done nicely but a second opinion in this era is certainly indicated.

Stop arguing, roll up your sleeves, and get back to work. It’s something that we have a national shortage of healthcare providers when they are all arguing on a stupid website about something they ultimately don’t have any control over.

It is simple really to explain the difference. There are many people who have taken flying lessons and now take to the air in their single engine Cessna or other small plane. They are pilots. So given the current logic of the argument why not let them fly a 747? It’s the same thing, right? So how many of you who support this ridiculous notion of eeveryone being a doctor (even without medical school) are ready to get on board that 747 piloted by the weekend Cessna flyer? And please don’t try and tell me that this is “different”. Take your Cessna license and get hired by AA to fly the big planes and then I will accept everyone into the fold. No other industry would put up with this nonsense!

FYI,In Iowa,NP”s are NOT supervised nor regulated as are PA’s.When I inquired as to why,I was informed by a party in Des Moines that the State Legislature & Senate have proposed,written,or voted on any law covering this area.So,in Iowa,NP’s are quite independent & woe betide anyone trying to change the status quo.

“So how many of you who support this ridiculous notion of eeveryone being a doctor are ready to get on board that 747 piloted by the weekend Cessna flyer? ”

I have a PhD; I have the right and the credentials to be called doctor. Physicians did not invent the word, nor do they own the word. DNP’s (or anyone else for that matter) are not calling themselves physicians, that would be unethical.

yes they can write well but ,thats all.in practcal situations they are helpless.practcality was best exemplified by the diploma nurse.true you march first in the academic procession as a phd.why do np’s throw the complex cases to the physician? if they are so confident in their abilities,then they should pay the same premiums for malpractice that physicians do for the same procedures.also,do np’s work more than 8 hours per day or do a specialty residency for 3 or 4 years?of course not. Np’s & pa’s are cheap labor in a specialty wild field.

BTW,doctor means teacher.As far as DO school is concerned,many of us chose it for general practice,at a time when md schools were preaching specialties only.That is why i chose kirksville over others that i was selected for such as cornell-flower 5th avenue ,tufts,indiana,etc.

Here we go again – PhD, RN writes:
“I have a PhD; I have the right and the credentials to be called doctor. Physicians did not invent the word, nor do they own the word. DNP’s (or anyone else for that matter) are not calling themselves physicians, that would be unethical.”
It is unethical and WRONG for you to call yourself doctor under circumstances wherein a patient would assume you are a physician. For instance, if you are working in a health facility as a nurse and you address your as doctor you are misleading the patient. At your own office, at an institution of learning, at social gatherings, etc call yourself whatever you want. So I hope you understand, you don’t have the right and the credentials to be called doctor under all circumstances.

1. They are Nurses -“advanced practice” or not.
2. They have the scope of practice defined by State law-usually the same as
any other NP.
3. They DO NOT have more education than a PA- IF the only thing that really
counts is medical science and clinical practice- the DNP has very little
medical science knowledge- as shown by exam performance and their
politically correct course work for the DNP.

4. The DNP is really a phony baloney “doctorate” in almost the same sense that
middle school principles get phony “doctor of Education” degrees to
puff up their academic qualifications in the most outrageous and absurd
manner possible- so they can then be called “doctor” and grab more
money and status for themselves.

5. It is crucial that the docs (the real ones) keep calling out and exposing the
conceits and phony non-sense that gets ENDLESSLY repeated in blogs and
in the media. It is now the year 2011, and STILL it is the case that the
BIGGER THE LIE, and THE MORE OFTEN IT IS REPEATED, the more likely
it will be accepted as the received truth- “PROOF” by force of
blaring, constant repetition.

Several years ago at a state chapter meeting being visited by the president of the AOA, I offered that the biggest threat to primary care was not mounting malpractice premiums but the influx of, and expanding scope of practice of, nurse practitioners. The response I received from some influential members was that the “nurse’s union was too strong to fight.” At this point, I would be elated if the AOA and the AMA used their resources to insure that NP’s be scrutinized by the same oversight boards that oversee physicians and PAs. That would be a major step and I suspect it would be eye opening since NP malpractice erros is buried somewhere in never land

Skeptical Internist – Wow,after reading your comments I am convinced to believe that you were breastfed by your father. You should be embarassed! If this is your biggest worry, you are obviously in the wrong profession. As a student in the healthcare field which I will not disclose, I am surprised I have not heard one word in the sense of COMPASSION or CARING. Healthcare is not a matter of money, who can be called “doctor”, or all ones political ideas; It is about taking the time to truly help someone that needs help, finding resources, and providing the best possible outcome for these people called patients.

Nothing I have said has anything at all to do with compassion and caring for
patients.

If anything, making certain that under qualified NPs are not allowed to
practice without adequate supervision IS compassion and caring for patients.

It is precisely the NPs who, using entirely inadequate “studies”, are the
the ones playing political games-as their constant yearly treks to the State
legislatures demonstrate.

Using the buzz words of “compassion” and “caring” is just the sort of
politically correct nonsense that passes for “reasoning” these days- just
because you use buzzwords, you appear to believe everyone should accept
whatever your position on the issues is.

At least ATTEMPT to make logical and reasoned arguments, as opposed to
impugning someone’s heritage.

“Skeptical Internist” I am not attempting to or even suggesting to bash your “heritage”. Taking care of patients is no ones “hertiage” it is a privilage provided to you when you accepted and committed to The Hippocratic Oath. All I am saying, is that I know MANY (more that I would like to know) MEDICAL DOCTORS that practice using inadequate studies, they also have extremely high infection rates (surgical), poor treatment in regards to prevention not utilizing evidence base guidelines (primary care), and others ordering tests that are not needed on patient (mulitple specialities). When I see a 93 year old person getting a bone marrow biopsy to “start chemo” is that really realistic? So for one to say NP’s are doing this is ludicrous. I also notice that you suggest adequate supervision of NP’s, instead of adding to the problem by being so narrow minded out inadequately trained NPs, you should consider training a few. Just to let you conscience rest and you can feed your ego knowing there is that ONE NP doing exactly what YOU SAY (I am sure you can find just ONE that will tolerate this behavior)! When I use the “buzzwords” compassion and caring, I am not attempting to make people believe in any position, it is the basis of healthcare in my moral standing and the foundation of medice (well should be)!

While reading these post I feel very defeated ad a Nurse Practitioner. I have a 2 year Associate Degree and practiced as a Registered Nurse for over 13 years. I decided to go back to school for my Bachelors degree after working in a Level one Trauma Unit in the Emergency helping Residents in the ER become the best that they could be. I was a Charge Nurse and became a Travel nurse, and a House Supervisor with my last job while I was going to Nurse Practitioner school. I chose to be trained by ER Doctors because I thought that I was going to be an NP in the ER. I loved the Doctor’s that trained me and I appreciate everything that they did teach me. I felt saddened as the Skeptical Internist kept putting everyone in one Melting pot as if all NP’s were bad. I do precept NP’s in the Independent practice that another NP and I run. I almost feel the same in that there needs to be some changes in the Colleges that if an RN enters into the NP Program they should have at least 5 years as an RN and also they should have at least 1 year of residency in the specific area of practice before being on their own. There should also be a 5 year of Supervision of an MD to at least have someone to inquire about different patient questions that should be needed. There are too many NP programs that are pushing out inexperienced Nurse Practitioners that are not ready to be on their own, but not all of us are like that. I am not a Physician and I do not have my DNP, and I tell all of my patients that I am a Nurse Practitioner and make sure that I am providing their care as a complete patient and not just one specific area that they are there for. I know that in being an ER nurse for so many years that it is easy to have a narrow focus and treat just one thing at a time, but since I have been in Family Practice I have learned to focus on the total healthcare of the patient. I DO NOT WANT TO BE A PHYSICIAN, but I want to be able to care for patients under the maximum of my scope of practice. I find it disheartening that there are people out there that do not want to accept that the Medical field is ever changing and focus on trying to change things instead of being on this specific site degrading a specific profession. I have dealt with too many ER Doctors that have looked down on the Nursing Profession and I have dealt with the best of ER Doctors that want to work together and band together as MD’s and NP’s to be able to care for our communities for improved and better patient care. I know where this one Physician is coming from and we as Nurse Practitioners need to make a change in our Education in order to bring us up to par with the acceptance in the Medical Society.

I’ve been a Nurse Practitioner for over 15 years, and work with a MD who has employed many NPs and CNMs over the years.When he first started doing this, it was not popular or well received in the community of Physicians, but over time, many area physicians have begun to utilize the help of NPs in their offices and in the ER. The physician I work for feels that the nurse practitioners can handle most of the yearly exams and common problems that present. He sees these patients too, but because the NPs see the low acuity patients, he has more time for those with acute problems or rare medical conditions, or those who have not responded to standard treatment. Speaking for myself, I have no interest in BEING a doctor, nor do I EVER let anyone refer to me as such. In my state, a collaborative agreement with a physician is required in order to practice, and the NP must practice within the scope of their specialty certification. All NPs learn when it is appropriate to consult or refer to their collaborating MD or DO. And they do this when the situation warrants it. Right now I am back in school for additional clinical specialty. Last week I spent clinical hours with an FNP in a college health care clinic. We saw about 20 -25 patients in the four hours I was there. The breakdown was something like 15 URIs, a couple UTIs, a couple of skin rashes and some probable STIs. These patients were all uncomfortable enough to be seen by a health care provider, without serious illness or emergent problems. Why not utilize the services of an NP for this? Dr. is available by phone, and the office/ hospital is 20 minutes away by car. And what MD or DO would take the time from his or her busy day to staff this clinic ? CLEARLY, there is room in the health care arena for BOTH NPs and MDs/DOs. WHY do we continue to have this debate? The physician I work with relies on his NPS to staff his office while he does surgery, attends meetings, goes on mission trips and supports community endeavors. He is in touch with staff daily if he is not in the office. Protocols developed by both MD and NPs guide NPs in decision making with regard to care and referral. There is room in health care for BOTH NPs and physicians for physicians who are smart enough to take advantage of the skills and services NPs have to offer. We ALL know excellent NPs and lousy doctors and vice versa. Lets just play nice, shall we? NOBODY disputes the MD or DO’s educational quality. This does not, however, diminish the quality of Nurse Practitioner education or NP ability to be a valuable and viable health care delivery partner.

I propose legislation requiring DOs to clarify that they are an inferior DO and NOT a MD when pts call them “(real)Doctor” in a clinical setting… just kidding.

I wonder if the Nursing community were to mimic DO and MD education with the DNP, would the DO and MD community still insist that DNPs are not doctors? I suspect the answer is yes.

Real or perceived, there is a primary care provider shortage. The government will attempt to fix this, with or without MDs and DOs. I think the most equitable solution is to increase the training requirements of DNP programs (but not to the extent of MD and DO programs, unless you want DNPs stepping in on you specialty territory as well) and keep masters level NP programs but limit there scope of practice to that of PAs.

I doubt this solution will please many “Doctors” but I believe it is the most pragmatic solution.

One of the essential elements as far as I am concerned is to never allow
other professions, like nursing, to tell us what qualifies as, and
what training is required for, medical practice.

Physicians go to medical school to practice medicine.

The NP “argument” for changing laws and standards for medical practice
really amounts to nothing other than brazenly swiping areas of medical
practice, and trying to use Nursing boards and State legislatures to
RELABEL these areas as “nursing” or “advanced practice nursing”.
This is, obviously, nonsense.

What other profession puts up with these shenanigans?

The DNP degree is NOT a medical degree
It is not a scientific degree.
It is a poltically-correct statement- an excuse for its holders to
claim a title they have not really earned.

Real doctors in clinical medicine go to medical school. That is a simple truth
that will not change and that the public can understand.

The public is not as foolish as “male DNP” believes: they can easily
understand what fakery really is.

As to the “shortage” of primary care:

The number of medical schools is increasing, and the medical profession
needs only to argue that family medicine and internal medicine programs
need to increase-both to meet projected demands AND to maintain
standards. I would add that we need more PA programs as well- so that
primary care physicians can partner with several of them and thereby serve
a very large number of patients.

PAs are better trained in medical science anyway; they do not engage in anything
like the political agenda that nursing does; and they often make excellent
physicians themselves when they undertake medical school.

Finally, last but not least, there has also been a shortage of bedside Nursing-
foolishly letting “DNPs” practice medicine will merely exacerbate another
shortage in another health profession- as well as lower standards.

I stand by my conclusion that DNPs are not “real” doctors in clinical,
medical and hospital organizations. They are Nurses. Period.

Post-script: why is the fact that you are “male” important? Are you invoking
the usual political correctness of the day? i.e, males do the DNP degree also,
therefore it is “legitimate?”

“Male DNP” also seeks obliquely to attack the medical profession
by pointing to the fact that “inferior D.O.s” practice medicine.

Once again, the osteopathic medical schools spent many decades
under-going self-improvement and building their own systems of
medical schools and hospitals. It took them decades to achieve a relative
parity with the MD schools. They undertook this task because they genuinely
believed they had additional aspects of therapy to bring to medical
practice-“manual medicine”.

It was the MD schools and residencies themselves that finally welcomed D.O. s
into medicine-by opening their Residency programs/Certifying Boards and
their complete and full Licensing exams.

In this manner, the medical profession now has CONSISTENT and UNIFORMLY
HIGH educational and training standards: SYSTEM-WIDE across medicine- BOTH
for D.O.s and for M.D.s

It is only the NPs who yammer about their incessant desire for “prescriptive
authority”. This is because that is what they SEE physicians do, and what they seek
to imitate.

But to the primary care physician, the MOST important aspect of their practice
is NOT writing prescriptions- it is to arrive at a careful and full differential
diagnosis of a patient’s problems and to undertake steps required to secure a
correct and accurate DIAGNOSIS.

To the PHYSICIAN, KNOWLEDGE AND DIAGNOSTIC ACCURACY is the key to
medical practice, not the trivial trappings of medical practice such as writing
prescriptions.

It is extremely telling that nurse practitioners keep up their endless din to
legislatures about “prescriptive authority”- a term physicians never use.
It clearly demonstrates that NPs in the forefront of their political movement
really care about illusions such as the appearance of being a physician and
their OWN “authority”- or relative level thereof.

With perfect hypocrisy, they then turn-round 180 degrees and accuse real
doctors of only caring about protecting their authority.

And all the while, it is medical knowledge and training in diagnosis that is the
key to good general medical practice- that which is NOT on trivial display, and
therefore NOT the object of Nurse Practitioner envy/jealousy.

Your ego and lack of civility aside, I am as much a Clinical Doctor as any PhD prepared psychologist, physical therapist, occupational therapist, dentist, optometrist, or chiropractor. Especially in the case of the psychologist who is often found in hospitals, prisons, and offices with psychiatrist. When I introduce myself I always say, “hi I am Dr. Male, I am a Nurse Practitioner” the same as all of the psychologists I know. I know many MDs who still consider DOs second rate doctors. By the way my last name is Male, but I do happen to be a man.

As far as my education goes I will be the first to tell you that my DNP program was hardly worthwhile. I am however more than qualified to do what I do, including full prescriptive rights in my state and a collaborative agreement that is little more than symbolic.

I would like to see an improvement in DNP programs. The current curriculum at most institutions is worthless. It could be changed to add curriculum covered in MD / DO programs and even an abbreviated residency. Unlike MDs and DOs, nurses generally have an undergraduate degree in nursing, there would be little need for a DNP program identical to MD / DO programs. Nursing could offer a different Physician perspective much the same way DOs do.

As far as the “nursing shortage” goes, it is largely a myth. There may be some areas in the US where RNs are in short supply but there are many where RNs are unemployed, especially new graduates.

Leaving aside “Male DNP’s” personal attacks on my supposed lack of
“civility” and my “ego” [ the fact that I am certain his arguments for
his position are dead wrong, of course, has nothing to do with such
attacks], this discussion is important for a few reasons:

1. First, it highlights what the true motives and intent of the NP
movement actually are, as opposed to the nonsense propaganda
spewed forth by their political machinery and aggressive legislative
agenda.

As can be plainly seen, “Male DNP” wants very badly to be viewed as
a Physician, and even states that “Nursing could offer a different
Physician perspective much the same way DOs do.”

So much for any pretense that they are NOT in fact trying to be
Physicians.

They just want to do this NOT by adding any method or branch to Medicine,
but just by having 1/10 the scientific background and far less rigorous
clinical training.

Of course, if they succeed, they will want equal pay and equal hospital
privileges.

2. Clearly demonstrated is Male DNP’s contempt for any oversight or
supervisory arrangement, or to use their own “politically correct”
language, “collaborative agreement”.

NPs clearly believe they have earned the right to practice medicine,
WITHOUT going to medical school ( even an “inferior” DO or
?foreign medical school). They believe they have earned this right
regardless of the plain facts.

This is why, in Iowa, the NPs wanted to supervise Radiology procedures,
as if they were Radiologists, when their background does not even
include one year of University-level Physics.

The unbridled arrogance and egotism that was demonstrated elicited
a Court injunction in Iowa to prevent this blatant and obvious risk
to patient safety (a Court action that was successful).

Now, for Male DNP himself:

With breath-taking illogic, you assert yourself that your DNP
program was hardly worthwhile [ not surprising, since a casual
review of these programs reveals all fluff and management
course work, and very little or zero medical science or clinical
training]. You even admit that the current DNP curriculum at
most institutions is worthless.

You then proceed to claim that you are “more than qualified to do
what you do” (practice medicine).

You thereby prove my point that the DNP is a political degree and you are
really claiming equivalence to other doctorally prepared health care
providers and physicians based on your Master’s degree in Nursing.

This obviously begs the question of why the DNP degree is needed as the
“highest practice degree” in Nursing. [Ans: its needed for political
reasons only, not “practice” reasons]
Obviously, nothing here stands up to reason, logic or scrutiny.
[feel free to start your ad-hominem attacks].

Yes, some MDs still consider DOs their inferior.

However, a great many MDs, in all specialties, do not.

You need to be taught the rules of logic, reason and evidence.
To wit:

– The DOs now take the USMLE, all three parts, and score very
closely to their MD counterparts, and BETTER than the foreign
MD graduates. Indeed, their clinical science scores and pass rates are
the same as US MD school graduates.

– A great many DOs then do the same residencies and are Board Certified
by the same Boards.

So you see, Male DNP, there is a difference between evidence and reason,
vs. prejudice.

I can clearly point to OBJECTIVE EVIDENCE and STANDARDS for asserting
that DOs and MDs are essentially equivalent ( and have been for many
years now).

HOWEVER, when the “DNPs” take their own SHORTENED and SIMPLIFIED
( you know Mr. Male DNP- EASIER) version of ONLY USMLE Part III:

– 50 % FAIL their own lower standards, a result that is highly
QUANTITATIVELY AND OBJECTIVELY INFERIOR to
American Medical School standards.
(in other words, it is not even close, like DO-MD).

And for this nonsense, you want equal pay, same titles, equal
privileges and so forth.

Absurd, as PART of your post above actually recognizes.

Last, but not least, the Nurse shortage is real according to the
AACN. At the AACN website, one may look up a 2010 fact paper
demonstrating the projected shortages-“NURSING SHORTAGE FACT SHEET”.

A great many organizations and statistics are stated there. The shortages
arise from the same factors producing the MD shortage- retirees from
Nursing, Baby Boomers retiring, high burnout rates, difficulty of RN schools
getting enough resources to increase and train more Nurses, etc.

It seems this nation can ill-afford the arrogance and the self-serving
propaganda of the NP movement, let alone the blithering pomposity of
the DNP movement.

But I do thank you for more fully revealing to the Physician community
the true motives and purposes of the DNP degree, and all the “ugly”
it really represents- this may serve to enlighten any unfortunate
colleagues who may well have been “snowed” by the NP agenda.

I agree with skepticalinternist. The DNP is absolutely a politically motivated power grab by the nurses associations. S-I : you’re a bit fiery but I think to some degree I’d feel the same way if I was in your shoes. There are a lot of passive physicians out there content to serve their patients and keep quiet. They probably don’t understand the damage they are doing on the fronts where they could still make a difference. I live in NY and go to a small private school. My FNP program is still a masters at this point, but they will be offering the DNP in the fall. The program is disappointing at best, and not challenging in the ways I find important.

I tend to think in a scientific way, basics first- Outline the big picture first, and then fill in the fine colors. This is not the way we are taught. It is fact based, not understanding based as it should be. No surprise, it’s hard for people to remember these tangential facts with nothing to tie them together. I’m a bit of a scientific thinker so I heavily self study what I think is important, patho, fundamental sciences, anatomy and physiology. People laugh at me for this. They say why are you still reading patho and physiology books? Didn’t you take that before you went into nursing? They just don’t get it. They are so focused on the goal, not on the learning experience. I find myself more and more every day desiring everything medical school has to offer (except the bill). That fantastic residency, those core sciences, the challenge… ummmmmmmm…. delicious. I’m not saying there aren’t great NPs out there….. I just can’t understand how they end up that way.

On another note it’s a little bothersome how many nursing students have the goal of becoming NP’s. I’m a nursing tutor at a community college, so I hear it all the time. What ever happened to wanting to be a bedside nurse?

That caring touch, the humanistic love of your fellow man, that’s truly the caring spirit of the profession and nobody can argue it. I really don’t think NPs can accomplish this effectively as a provider. Its about being there, the every day grind, coming in early and leaving late. Time is no doubt the major problem. NP’s just don’t have the time to do this in the provider role. Maybe they possess the attitude, maybe they have it in them, or maybe they have felt that connection before, but what counts is being there. Those who can, do, right? All these students just care about the money and power of the role, these are the same attitudes driving the DNP. I am a hypocrite, I’m not going to argue it. I think its because of societal factors, my generation wants everything easy, the quick reward, and I do too but don’t think for a second I don’t see the problem with it. I’m trying to fight the urge but its tough. The NP is a troublesome imposition, not quite a “nurse” and not a “doctor”. Not quite caring, not medicine…..what are we?

Having said that, the DNP is a fluff degree that offers little if any contribution to clinical skills of practitioners over masters-prepared NP’s. Frankly, even if you don’t buy in to it being a politically motivated power grab, you’ve got to question it’s purpose. Why the push to make the DNP the entry degree for NPs? At best, it’s unnecessary.

If nursing leadership is truly interested in furthering nursing education and insists on making the DNP the standard for NPs, and they are serious about wanting to be considered clinical equals to physicians, I suggest they go about it the right way:

1. Be honest about the “nursing model” vs. “medical model” rhetoric. It is disingenuous to pretend that what NPs mean when they say “independent practice of advanced nursing” doesn’t mean, or at a minimum include practicing medicine.

2. Hold themselves to a higher standard in terms of licensing requirements. Require NP students to pass exams on par with the USMLE or COMLEX exams, and set goals that NP students do so at a rate comparable to MD/DO programs.

3. In order to meet those goals, radically alter the curriculum of DNP programs to equip students to do just that. This probably means cutting some of the fluff, adding rigorous science courses, and significantly increasing the clinical requirements.

4. Either drop the rhetoric about NPs being essential to increase access to underserved areas and an answer to primary care shortages, or find a way to make it actually happen. The fact is that as it stands, NPs are geographically distributed in similarly to physicians. Underserved areas are still largely underserved. What is more is that NPs are moving more and more away from primary care and in to specialization.

I’m an RN with 24-years bedside experience. I can tell you, there is a difference between book learning and practical experience. I have heard MD teachers state that they think the students coming out of med school are the stupidest they have ever had to deal with.

I’ll leave the nuances of this fight to those with the degrees. My plea would be for the MDs, the so-called “real doctors,” to come to the bedside and talk to their patients. It’s a little disconcerting to hear a patient say that they have not seen or heard from a “doctor” in 4 days and “Please tell me what is wrong with me?” Of course, I know, but I am not allowed to discuss this with the patient because I am not the medical side. I have to refer the patient to the phantom doctor who comes to the bedside to visit the chart.

At a certain point, patients will be happy to get to talk to anyone! I have taken the time to explain certain things to patients only to have them tell me, “Thank you! No one’s bothered to talk to me.” This is an absolute disgrace to the medical profession, and little respect will be given to your arguments unless you make it a priority to teach your students–no, require them–to talk to patients.

Don’t tell me how great you are–I know what you do, and how patients are failed every day by great, learned docs who don’t have the time of day for sick people.

I was trying to learn more about the debate between physicians and NPs. The article included both the physician and nursing views which was pretty good.

I do think Skeptical Internist is being a bit unreasonable, short-tempered and verbally abusive. I’m pretty sure you’ll go on to attack my post next as well, but it’s alright, I’m probably not going to check back here over & over, like you have.

I just want to state that I agree with many others:
– 3rd year medical students are highly incompetent & will require help from nurses to become competent (so why are we attacking nurses so much?)
– NPs do not have as much education/experience as physicians, but really, most medical students I know do not WANT to go into primary care- it is often a “fall back” residency & most people I know who get high scores on their USMLE exams will choose a specialty that has better work hours, pay, etc.
-If physicians cannot fill the primary care shortage, then who are we suggesting? It is silly to do telemedicine with only PAs if patients want to actually be seen by a physician.
-I agree with others that physicians don’t spend nearly enough time with patients. For my most recent checkup, I found the physician to be rude, dismissive of my concerns and she never gave me a chance to even ask her questions! I was very annoyed when I left & thought, “maybe I should have become a nurse if as a physician, I will only get to talk to my patient for 5 minutes while the nurse does everything else” But I do understand that some of that is the demands put on the physicians- they are expected to see some 40-50 patients in a day so of course time/patient is going to be short. I just wish physicians didn’t have to see so many patients every day.

But that is not to say I’ve been impressed by the nurses I’ve met, either. I’ve met some great nurses, but there have also been some who were just bitter, rude, dismissive and mean to patients, especially at nursing homes. Of course there will be bad physicians and bad nurses, just as in all areas of life.

Also, I am on the side of the doctors regarding the malpractice case studies- if NPs are being supervised, of course they will not get sued, it will be the physician and residents being sued. What are the statistics for INDEPENDENTLY practicing NPs?

And the USMLE Step 3…if it’s a shorter & possibly easier test, then that cannot be said to be “equivalent” to an MD/DO. One of the hardest things about the Step exams is the duration of the test. You need to have the stamina & be able to maintain sanity to make it through 8 hours of testing!

Also, my friend who is getting her master’s in nursing has told me that the whole reason hospitals and nurses want to make it mandatory for nurses to get a DNP over a master’s is that compensation for master’s is 80% of what physicians would get compensated while for DNP is 100%…so maybe $ is a bit of a motive?

Overall, I don’t think NPs should practice independently because I feel like they need supervision from a physician to correct their errors, but I think there is nothing wrong with them using the term “Doctor” as long as they explain that they are NPs. Then if they are implicated in a malpractice lawsuit while practicing independently, patients will not think that physicians are the ones being sued.

Also, skeptical intern, I feel like if you toned down your attacks a bit, it would all sound much more reasonable. As of now, it’s hard for anyone to trust what you are saying since you sound extremely biased & will turn what anyone says around to suit your needs. That’s not how reasonable, educated people argue their points and relentlessly attacking the other side will not win you any supporters.

Medical Student MD/MPH…As for malpractice stats for NPs, check the Pearson Report for all those states allowing NPs to practice independently…I think you’ll be surprised.

I am beyond words for expressing my distaste and embarrassment over the immaturity demonstrated on this site. Most of the behavior here is deplorable. I’ve recognized many behaviors seen in the APA DSM. Get some help!

Medical education in the US is a but ridiculous. In most other countries in the world Medical Doctors only have Bachelor degrees in Medicine. Would American MD’s argue that they are the only REAL Doctors on the planet then? Since their foreign doctors did not go through the same years of schooling as they did. Honestly, why in the world would you need a bachelors degree prior to getting into a medical school? Do you really learn a lot of medicine in your undergrad? Those Med School prerequisites for admissions take no longer than two years to complete. Requirement to have a university degree before getting into a med school only exist in North America. And medical schools are no longer able to produce enough physicians for people. Something must change about the healthcare in this country. NP’s is a great alternative – they don’t study things that are not related to Medicine in their programs (I know doctors that did Music/Business (you name it) in their undergrads, that sure helps them to manage diseases. NP’s don’t go through the extra odd years of schooling, allowing them to have much less student debt. Having less debt means that you don’t need to make as much money as an MD, because you start working earlier with a much less debt. But since NP’s do the exact same thing as some physicians, why pay more to those with MD degrees? The country is in a huge debt, a lot because of healthcare. Thirty percent of government spendings goes towards healthcare.
American Medical Association should attack foreign doctors for only having BS in Medicine. After that most of us will lose any access to primary care.

Allen T
Without arguing the numerous false assumptions in your post, if we were to follow your argument/logic then the actual amount of post baccalaureate medical education an NP has accumulated is 30 class credits and 850 clinical hours. I doubt most patients would feel comfortable putting their health and life as well as their loved ones health and life in the hands of a physician with that meager amount of training yet it doesn’t seem to bother you.

Fixemup

Nothing I’ve read here is as embarrassing as your statement which follows –

“I am beyond words for expressing my distaste and embarrassment over the immaturity demonstrated on this site. Most of the behavior here is deplorable. I’ve recognized many behaviors seen in the APA DSM. Get some help!”

Wow I find it amazing you can recognize and diagnosis from just a few statements found in a post. I have never met a physician who felt that that was adequate enough contact to come to a valid conclusion.

MDs/DOs commit themselves to many years of student loans and hours of residency training.
They’ve earned the privilege and right to be called “Doctor” of medicine and to practice medicine.
A charge nurse with 25 years plus experience has valuable experience to offer and teach to future generation of residents, nursing students, health careprofessionals..

I’m a full time paramedic In a very busy urban 911 system, soon to be post-bacc student with a bachelors in music.

Now looking back, the Practice of brinigng the EMERGENCY Room ER acute emergency to the bedroom with about a year of training and formal education and the minimum qualifications of a high school equivalent degree is absurd.
Granted access to the initial start of Patient care privelges for True emergencys from Recognizing STEMI’s, the LAD “widow makers”, Tight asthmatic, Acute Oulmonary Edema, diabetic and seizures, CVA, traumas, gynecology emergency etc.. And the routine alcohol and substance abuse to the common cold, psychiatric illness.

For the most part the General public and especially indignant population do not know the difference or care as long as they get treated properly with dignity and respect.

With all the skills and quick thinking clinical practice under a physicians license. A paramedic/EMT Never will all the experience equate to that of a fully educated and trained MD/DO.
But In most cases the public does not know the difference from an EMT and a paramedic since practice do vary locally and by state.

Modern times has Policy and Protocols changes, patient needs and situation changes, Hospital practice and working environment dynamics and corporate policy at times seem to work against each objectives and argument to reach the final goal of the medical professions.

A Lack of solid base foundation in a rounded education promotes inflexibility and will only increase a work ethic and culture of self motivated incentives. Workplace drama and employee situations and territorial turf war over market share.

Calling a mid-level practitioner a doctor will add much confusion to an already controlled chaotic profession.

I am an Average Joe, I don’t have a PhD, I am not a Republican or Democrat, I am an average consumer trying to make sense of this whole Affordable Care Act. I am reading as much info as I can and I am scared for myself and my family. I don’t know who is who-you guys all run around in long white coats and call yourself doctor. I live in Calif where I have now found out that the Lens Crafters optometrist and CVS pharmacist will be soon be allowed to prescribe blood pressure medications and diabetic medications and they call themselves doctor too. This is very confusing. Can you guys wear some kind of ID that lets me know who is a medical doctor and who not. Sometimes I am talking with someone in a long white coat and I think I am talking with a medical doctor and I am not, it’s all very confusing. I don’t understand why the Affordable Care Act means I have to get care from someone who isn’t a medical doctor. I was upset by reading the above disscussion about nurse practioners- that 1/2 failed the physician licensing test or that they don’t have the same amount of hours of training that a physician has or that they can take classes on line. I don’t like knowing the pharmacist are going to be treating some medical conditions or my eye glass doctor will give meds for diabetis. The other idea that is upseting me is reading the nurse practitioner above who said that he/she would not give a 93 year a chemo drug if they needed it. I am not into this die with dignity crap, I plan on going out fighting! That fried my butt to hear that! I am a triathlete and in a short time when I become 93 I hope that nurse practioners use better scientific reasoning than age discrimination to make discisions about health care. If that is the new type of reasoning which is part of the new nurse model thinking I don’t want it! If I find a nurse practitioner, CVS pharmacist or Lens Crafter doctor that denied me care, I will haunt them thru eternity for that deed!

I don’t understand if there is a doctor shortage why not open up more doctor teaching places? There is a nursing shortage I understand, why can’t our nurses go to school be the great nurses that they are and let the medical doctors be doctors? I think we have great nurses, and if nurses want to go to medical school to become doctors, I am all for it.
I just find it curious that when we don’t have enough medical care for the baby boomers that we resort to a Scrooge mentality of decreasing the surplus population by having lessor trained people treat the masses. People are going to be hurt by this plan. This is why as a consumer that I am scared.

I really cannot believe that a group of well-educated physicians are bickering about what a patient calls a person with an earned doctorate. The doctorate degree entitles that person to be called “Dr” if they so wish. There are no stipulations that come along with your “DO” that say you cannot be referred as “Dr” when you step into a University where the norm is a “PhD” or “Ed.D”. The list can go on and on…

For the most part, people enter the profession to help others. Nurses are not trying to take over our role as a physician, it is now another option for patients (just like the option of a “DO” came along at one time instead of a “MD”). However, if we as a group do not start caring more for the patient instead of how many of them we can see, the nurses may just take over and we will not have anyone to blame but our self.

Perhaps if you cared for the patient as deeply as you care about what they call you or your DNP counterpart then we would not even have a need for this conversation.

With the Rise of the DNP, well, perhaps DOs should change their degree to MD,DO now so that patients will know MD behind someones name means Medical Doctor. DO & DNP confuses patients. DOs : change your archaic degree title to MD,DO now.

I’m a patient & I see a DO. She told me that most likely the DO degree will be changed to MD, DO once the old stubborn current DO osteopaths retire from the AOA. Then, the new modern DOs will be in power and wull yhen change the DO degree to MD, DO.

Your hostility is downright appalling and I do not believe that energy is going to further your cause. You are crying a river about how rigorous path is to becoming a physician and you have yet to put yourself in other people’s shoes who have chosen other routes to achieve their profession as well. In my program there is a 30 year veteran to the field of nursing and an Army nurse who served our country in Iraq for a number of years. You forget that all those who are MSN-NPs or DNPs were nurses first and that not an easy career path either. We have years of experience bedside not to mention experience in taking care of your mistakes. While you see patients for 10-15 min each, we were by their side all along.

You talk about hallucinating after studying, how about doing a double or triple shift with no downtime and have complete accuracy and still hold it together to respond to emergent situations if needed. If your program is too rigorous, you probably should take a semester off because I do not believe that a “hallucinator” could necessarily be considered a safe practitioner…

Your complaints and insensitivity are so tired. Too bad the idea of a dermatology residency at USF (yes it actually exists already) for APRNS gets you heated because friends of mine have graduated from that program and are great at what they do and are LOVING their jobs. The purpose of an NP residency is to enhance learning in a specific field of choice not to become an “impostor” doctor. You have it so twisted!

I guess we will have to wait and see what the repercussions of the ACA will have in store for us all. Autonomy for NPs nationwide will inevitably flourish due to the influx of patients so the system will need us even more. For that I am happy because I got into the health care profession to care for the underserved in our communities not to take your job or your “steal” your title. BTW there is no big deal with a DNP nurse wearing “Doctor of Nursing Practice” on their name badge. They earned it and who are you to downgrade that? They are not stating they are MD’s or DO’s and you of all people should understand (being so scholarly) how much pride they have in that accomplishment.

Now please get back to your studies. You are wasting your valuable time trolling this thread.

I work with the best physician and PA in this world and know that I can out doctor many doctors in my community because of the training I have received from my mentors but also know when and where to go for help when I am in over my head, this is something many family DO’s do too late because they think they have to prove they are as good as MDs.

Stumbling upon these commentaries regarding Nurse Practitioner status and whatever threat is being perceived by DOs and MDs has prompted me to weigh in from my perspective of 30 years as a hospital/clinic based internist.
Firstly, so much of this reminds me of what the MDs spewed about our lack of training, inconsistencies, separate unverifiable boards and such in the early 80s. From this perspective, knee jerk hostility feels way to hypocritical to me; the degree of protest from Skeptical Internist, while spirited seems overboard to the point of perceived emasculation. My observations over the years regarding NPs is that the vast majority of them practice within their scope of knowledge, and because of that, naturally, from our perspective “over consult, and “over test”. But if you think about this, that is what a good NP has to do with their training base. What would be scary, and potentially harming to patients is a NP who did not understand their limitations and fail to recognize that a patient was indeed suffering from an illness unclear to the NP. What many physicians might say is that a person with limited training should never be placed in this position of responsibility. But our society has demanded it whether political or economical. So I say our best move as MDs or DOs is to provide collegial accessibility in order to optimize care for our patients.
I have maintained this approach interacting with PAs and NPs in the community without actually employing one. I have been treated with utmost respect from them, many are now my patients, and they feel thankful and grateful to bounce things off me, send me complex cases before ordering another MRI, or a Nephrology consult for a GFR of 55, or a cardiology consult for a PVC. Yes, mistakes are made. Join the club. Ostracizing is counter productive. I have never seen a PA or NP upset at corrective guidance. I have seen doctors puff their chest out and rebel in the same situation though….
I frankly don’t care whether or not a patiently mistakenly refers to them as a doctor or not. I know what I am, what my capabilities are, and how I got there. And so do they. Practicing medicine is rewarded individually and personally. Anything beyond that is meaningless. Harboring anger for allied care providers is as someone once said “like taking poison and waiting for the other person to die”. Utilize these providers as a resource, not as an enemy; demanding respect will never result in personal reward.

I don’t mind the concept of expanding the role of NPs and PAs, but we need to clearly define what the term “doctor” signifies in a clinical scenario.

A doctor is considered the final authority. Someone that; not only, has an understanding of how diseases manifests in a clinical setting, but also has an ability to explain to the patient the biomedical nature of what’s going on. And if we’re being absolute about what the word “doctor” signifies in westernized medicine, I would also state that the term “doctor” is an individual that can analyze scientific journals and also communicate in medical jargon with research institutes.

Until a PA or NP can competently perform these tasks, the term “Doctor” is not appropriate. Just saying: I was talking to a first year PA student and they didn’t understand what a PCR was. In my biased and un-professional opinion this is not the kind of person that should be given the title of “doctor”. He or she is not an expert.

Also, one last note I would like to make:imo studies that argue for the competency of PAs and NPs are worthless. You can take data and skew the results to fit whatever you want your conclusion to be. But let’s pretend that such a thing would NEVER happen ;).

Once upon a time the DO was not considered equal with MDs.
Nursing is evolving and a DNP is well deserving of the title doctor with no explanation needed. I would also like to point out that many foreign doctors have less education than the DNP. Some countries only require 6 years before step 3. Those doctors than come practice in the U.S. Also, to become a DNP you must first be a RN, which takes about 4 years. That plus the time to get NP/DNP is about 8 years.

Skeptical Internist seems pretty tightly wound (ad hominem). 50+ years of research shows that despite the differences in education, NP outcomes are the same or better than any physician.

The constant barrage of opposition to NP’s has nothing to do with patient safety or outcomes. Every argument is “secretly” grounded in the fact that organized medicine wants to hold on to their rapidly shrinking piece of the money pie.

Physicians’ “medical school” is closely related to a “fraternity” at the undergraduate level. The cronyism is hilarious, and if one doesn’t elect to traverse 4 years of “memorize/regurgitate” and then another 3 of “work for 40k and get treated poorly,” one isn’t a true “doctor.”

The best part is that patient outcomes are no different. In other words, stop wasting your time.

I obtained my MD in 1967, and went back to school 8 years ago. I am now a fully certified NP, and proud of it.

@NP Maloy, I don’t know what circles you’re in besides AARP, but based on your argument “NP=MD” would quite certainly mean that DOs are less than NP’s. Maybe you typed it wrong, maybe you meant DO=MD, because I can assure you, no one in this nation, would agree with what you just said.

The American Medical Association used to call Osteopathic medicine a cult. So having fought that long, hard battle of being recognized despite having a different perspective and philosophical foundation you just joined their club…